Assays for resistance to echinocandin-class drugs

ABSTRACT

Nucleic acid amplification assays for mutations to two short sections of the fungal gene FKS1. Mutations in these target sequences have been shown to correlate with resistance to echinocandin-class drugs. Assays may include detection by sequencing or by labeled hybridization probes. Also, primers, probes and reagent kits for performing such assays.

CROSS-REFERENCE TO RELATED APPLICATIONS

This Application is a National Stage Application based on International Application No. PCT/US2006/029290, filed Jul. 26, 2006, which claims priority benefit of U.S. Provisional Application No. 60/702,756, filed Jul. 26, 2005, the disclosures of which are incorporated herein by reference.

TECHNICAL FIELD

This invention relates to nucleic acid assays for fungi.

BACKGROUND

Fungal infections are a significant cause of morbidity and mortality in severely ill patients, and their impact is exacerbated by a failure to rapidly diagnose and effectively treat these infections. The widespread use of antifungal agents has resulted in selection of naturally resistant fungal species, as well as the emergence of resistance in susceptible species. Treatment of fungal disease is hampered by the availability of few classes of antifungal drugs. Recently, caspofungin was introduced clinically as the first of a new class of echinocandin drugs that target the fungal cell wall by blocking β-(1→3)-D-glucan synthase. Caspofungin use is growing rapidly, and clinical isolates of Candida species with reduced in vitro susceptibility are being reported with a strong correlation between treatment failure and high in vitro values of minimum inhibitory concentration, or MIC. As patient exposure to caspofungin increases, and as the other echinocandin drugs, including micafungin and anidulafungin, enter the market, it is anticipated that the number of clinical isolates with elevated MIC values will rise.

An aspect of this invention is nucleic-acid assays that detect genetic mutations associated with resistance to echinocandin-drugs in fungi, including but not limited to fungi of the genus Candida.

Another aspect of this invention is such nucleic-acid assays that employ exponential nucleic acid amplification of specified regions encoding the FKS1 protein, coupled preferably either with sequencing or detection utilizing labeled allele-discriminating probes.

Another aspect of this invention is kits of reagents and oligonucleotide sets of primers and probes for performing the foregoing assays.

SUMMARY

Echinocandins are the first new major antifungal drug class to enter the market in decades. Maintenance of the fungal cell wall integrity is essential, as a fungus cannot survive without this structure, or even if it is markedly altered in some way. The wall is an extracellular matrix with a layered organization consisting of an outer layer of glycoproteins and an inner layer of carbohydrate polymers including glucan, chitin and galactomannan. In saprophytic and pathogenic fungi, the carbohydrate layer is comprised mainly of β(1→3)-glucan and α(1→3)-glucan, but it also contains some β(1→6)-glucan and chitin. Glucans are also released from the fungal cell wall as exopolymers into the blood of patients with fungal infections, and are known to activate a wide range of innate immune responses. The fungal cell wall is a dynamic structure, as constitutive polymers are constantly being chemically modified and rearranged during cell wall biosynthesis. For example, Fks1p, the presumptive catalytic subunit of the glucan synthase complex responsible for β(1-3)-glucan formation is known to be co-localized within cortical actin patches. It moves on the cell surface to sites of cell wall remodeling, and cells with immobilized Fks1p exhibit defective cell wall structure and function. Fks1p is the product of the FKS1 gene. Echinocandins are cyclic hexapeptides N-linked to a fatty acyl side chain and inhibit the β(1→3)-D-glucan synthase, which is responsible for biosynthesis of the major cell wall biopolymer. The echinocandins drugs, caspofungin, micafungin, and anidulafungin are the first of a new class of antifungal compounds that target the fungal cell wall by blocking β-1,3-glucan synthase. The safety and tolerability of caspofungin, the first approved drug, in the treatment of fungal infections have been evaluated in a number of recent studies, with no serious clinical or laboratory drug-related adverse events reported in the majority of patients.

These drugs have broad-spectrum antifungal activity against Candida and Aspergillus spp. without cross-resistance to existing antifungal agents and therefore are effective against azole-resistant yeasts and moulds. Importantly, due to their critical affect on the cell wall, echinocandins are fungicidal with yeasts. They are active against moulds, but only appear to block the growing tips of hyphae. However, they are less active against invasive Zygomycetes, Cryptococcus neoformans, or Fusarium spp. Nevertheless, they are highly effective clinically against Aspergillus spp. Caspofungin has been approved in the US and other countries for the treatment of a number of serious fungal infections including invasive aspergillosis in patients who are refractory to or intolerant of other therapies, esophageal candidiasis, candidemia, and other Candida infections (including intra-abdominal abscesses, peritonitis and pleural space infections). Caspofungin is also indicated for empirical therapy of suspected fungal infections in patients with persistent fever and neutropenia. Caspofungin is now widely used along with triazole drugs, like voriconazole, for primary antifungal therapy against yeast and moulds. The entry of the closely related drug micafungin and anidulafungin will further extend the scope of this highly efficacious new class of drugs within the clinical community.

Since the first approved echinocandin entered the market in 2002, caspofungin use in the clinic has been growing rapidly, especially as the label for caspofungin in the U.S.A. was recently expanded to include esophageal candidiasis, candidemia, and other Candida infections, as well as empiric therapy. Clinical isolates of Candida with reduced in vitro susceptibility to caspofungin have been described, and a correlation between in vivo failure and rising in vitro caspofungin MIC values has been noted, although a strict correlation between minimum inhibitory concentrations (MIC) values and clinical outcome has not yet been established. As patient exposure to caspofungin increases, and as micafungin (June 2005) and anidulafungin enter the market, it is anticipated that the number of clinical isolates with elevated MIC values will increase and an increasing number of patients will fail therapy due to reduced drug susceptibility.

This invention includes nucleic acid assays to detect mutations in fungi such as yeast of the Candida genus and moulds of the Aspergillus genus, that confer resistance to the echinocandins class of drugs, including caspofungin, micafungin and anidulafungin. The assays are suitable for any samples containing or suspected to contain the fungus, including but not limited to samples obtained from humans, for example, blood, urine or tissue samples. Candida species include C. albicans, C. krusei, C. guillermondii, C. glabatra, C. tropicalis, and C. parapsilosis. Aspergillus species include A. fumigatus, A. flavus, A. niger, A. nidulans and A. terreus. Targets for the assays are nucleic acid (DNA, RNA) sequences corresponding to one or preferably, both of two conserved regions in the FKS1p family of proteins. The region that we refer to as the first region, or HS1, corresponds to the Phe₆₄₁ to Pro₆₄₉ of amino-acid sequence CaFks1p. Nucleic acid target sequences for the assays of this invention correspond to that conserved region but may correspond to one, two or a few, up to five, additional amino acids on either or both ends of each conserved region. The region that we refer to as the second region, or HS2, corresponds to Asp₁₃₅₇ to Leu₁₃₆₄ of amino acid sequence CaFks1p. Nucleic acid target sequences for assays of this invention correspond to that conserved region but may correspond to additional amino acids on the ends, from amino acid 1345 to the amino acid that is one, two or up to five beyond Leu₁₃₆₄ of CaFks1p, for example amino acids 1345-1369. Using laboratory strains and clinical isolates we have identified a number of mutations conferring echinocandin resistance in those regions. Among the laboratory strains we have used are CAI4 and M70 (see Example 2) and laboratory mutants that we generated (designated herein as “NR” strains, for example NR2). From the laboratory strains and clinical isolates we have identified a number of single amino-acid changes that impart resistance, including F641L, F641S, S645P, S645Y, S645F, D648Y, P649H, R1361H and R1361G, and a number of SNPs responsible for the amino-acid changes.

Assays of this invention include amplification of nucleic acid sequences that include the foregoing target sequences, that is, the nucleic acid target sequences, either DNA or RNA, that correspond to, or encode, the amino acid sequences described above. Any exponential amplification method can be used, including, for example, PCR (polymerase chain reaction) (see U.S. Pat. No. 4,965,188 and published application WO 03/054233A1), LCR (the ligase chain reaction), NASBA (nucleic acid sequence based amplification), SDA (strand displacement amplification), 3SR (self-sustained sequence amplification), TMA (transcription mediated amplification), and Q-beta replicase-mediated amplification, all of which are well known in the art.

Detection of mutations in the amplified target sequences may be by any method, including but not limited to sequencing methods and detection using labeled hybridization probes. Sequencing methods include, for example, traditional dideoxy sequencing and pyrosequencing, both known in the art. Detection utilizing hybridization probes can be performed following amplification, that is, end-point detection, or in real time, that is, during the course of amplification. Real-time methods employing hybridization probes include the 5′ nuclease detection method described in U.S. Pat. No. 5,487,972 and U.S. Pat. No. 5,538,848; detection utilizing molecular beacon probes described in U.S. Pat. No. 5,925,517; detection using FRET-probe pairs; detection using double-stranded probes, described in Li, Q. et al. (2002) “A New Class of Homogeneous Nucleic Acid Probes Based on Specific Displacement Hybridization,” Nuc. Acid Res. 30: (2) c5); and minor grove binding (MGB) probes, described in Afonia et al. (2002) “Minor Groove Binder-Conjugated DNA Probes for Quantitative DNA Detection by Hybridization-Triggered Fluorescence,” Biotechniques 32: 946-9.

Probe-detection methods of this invention utilize at least one probe that is allele-discriminating; that is, a probe that will hybridize to, and lead to signal generation from, one allele (for example, the wild-type sequence) but not another allele (for example, a mutant allele) under the detection conditions employed. Allele-discriminating probes generally have a rather short binding sequence, typically not more than 25 nucleotides in length and often 5-10 nucleotides shorter than that. Detection of drug-resistant mutants according to this invention may utilize more than one probe to interrogate an entire target sequence. Multiple probes may also be used to identify a particular mutation, that is, one probe specific for each mutation known or suspected to occur at a particular nucleotide position. Multiple-probe assays may include parallel amplifications, each containing one probe as well as assays that are partially or totally multiplexed, wherein each reaction vessel includes two or more different probes.

Assay kits according to this invention include probes and amplification primers. Generally the primers do not serve as reporter probes, but they are not prohibited from doing so. For example, so-called “scorpion” primers include attached hairpin, or molecular beacon, probes. Whitcombe et al. (1994) “Detection of PCR Products Using Self-Probing Amplicons and Fluorescence,” Nat. Biotechnol. 117: 804-807. Assay kits preferably include all reagents needed for amplification and detection, at least necessary primers, probes, polymerization enzymes and dNTPs. Assay kits may include primers and probes for other purposes, for example, amplification of control oligonucleotides. Kits may also include sample preparation reagents.

This invention also includes sets of oligonucleotides that include at least primers and probes for an assay. Control oligonucleotides may optionally be included in such sets.

The details of one or more embodiments of the invention are set forth in the accompanying figures and the description below. Other features, objects, and advantages of the invention will be apparent from the description and drawings, and from the claims.

As used in this application, certain abbreviations are used.

GS is an abbreviation for glucan synthase.

Fks1p is the abbreviation for the Fks1 protein, currently ascribed as the catalytic subunit of glucan synthase complex responsible for β(1-3)-glucan formation.

FKS1 is the gene encoding Fks1p.

CaFks1p is the Fks1 protein of C. albicans.

CaFKS1 is the FKS1 gene of C. albicans.

Ser₆₄₅ is the conventional nomenclature for designating an amino acid, in this example serine, and its position in a protein. In CaFks1p, serine is amino acid number 645.

S645P designates a mutation, indicating first the amino acid of the wild type protein (in this example “S”, serine); next the amino acid position (in this example “645”, indicating Ser₆₄₅ as the wild-type); and finally the mutant amino acid (in this example “P”, proline).

T1933C designates a gene mutation at nucleotide position 1933 from a T to a C. In the gene CaFKS1, nucleotide position 1933 occurs in the triplet coding for Ser₆₄₅ of CaFks1p, and the mutation results in an amino acid change.

SNP is the abbreviation for “single nucleotide polymorphism.”

BRIEF DESCRIPTION OF THE FIGURES

FIGS. 1A and 1B set forth the gene sequence CaFKS1 (GenBank Accession number D88815), with regions wherein mutations conferring echinocandin reduced susceptibility are underlined.

FIG. 2 is the amino acid sequence CaFks1p (GenBank Accession number BAA21535), with regions wherein mutations conferring echinocandin reduced susceptibility are underlined.

FIG. 3 depicts alignment of amino acid sequence of Saccharomyces cerevisiae Fks1p with the amino acid sequence of Candida albicans Fks1p.

FIG. 4 sets forth sequences of primers, probes and probe targets utilized in the Examples.

FIG. 5 is a plot of real-time PCR assays fluorescence curves from heterozygous samples.

FIGS. 6A-6D are plots of real-time PCR assays fluorescence curves from homozygous samples.

FIG. 7 depicts the format for detection results of multiplex real-time assays.

DETAILED DESCRIPTION

The FKS1 gene of fungal species transcribe to corresponding messenger RNA (mRNA), which translates to the 1,3-β-D-glucan synthase (GS) subunit Fks1p. Assays according to this invention are designed to detect mutations in either or both of two short gene regions that are conserved among fungal species. Both the amino acid sequences of Candida and some Aspergillus species and their corresponding gene sequences are known.

Several sequences for CaFKS1 are available. For the design of amplification primers and probes, we relied on three: GenBank accession numbers D88815, F027295 and CA2043. FIGS. 1A and 1B present the nucleotide sequence D88815. FIG. 2 presents the amino acid sequence of CaFks1p. In FIGS. 1A and 1B the two short DNA sequences that are included in targets for assays of this invention are underlined. Those sequences for CaFKS1 span nucleotides T1921 to T1947 and G4069 to G4092. In FIG. 2 the corresponding short amino acid sequences of CaFks1p are underlined. Those sequences span F(Phe)641 to P649 and D1357 to L1364.

For locations of amino acids in different fungi producing Fks1 protein, routine alignment indicates position. FIG. 3. illustrates alignment of C. albicans and S. cervisiae. Above the line is the wild-type protein of C. albicans, CaFks1p, for the portion of the sequence from amino acid 641 (Phe₆₄₁) to amino acid 649 (Pro₆₄₉). That sequence closely resembles the Fks1p amino acid series of S. cerevisiae, but for amino acids 639 (Phe₆₃₉) to 647 (Pro₆₄₆). Below the line is the wild-type protein of C. albicans, CaFks1p, for the portion of the sequence from amino acid 1357 (Asp₁₃₅₇) to amino acid 1364 (Leu₁₃₆₄). That sequence closely resembles the Fks1p amino acid series of S. cerevisiae, but for amino acids 1353 (Asp₁₃₅₃) to 1360 (Leu₁₃₆₀). Similar alignment can be done for Fks1 proteins of other fungal species.

A description of the relevant amino acid sequence of one species is sufficient to enable persons in the art to ascertain the gene sequence corresponding to that amino acid sequence, and vise versa. Further, a description of the location of the relevant amino acid sequence of one species is sufficient to enable persons in the art to ascertain the location of the corresponding amino acid sequence of other species and, hence, the location of their corresponding gene sequences; and a description of the location of the relevant gene sequence of one species is sufficient to enable persons in the art to ascertain the location of the gene sequence in other species and from that the location of the corresponding amino acid sequences. Because we have worked primarily with C. albicans and C. krusei, the description herein is based on the C. albicans amino acid and gene sequences. The sequence of the FKS1 gene of C. albicans (CaFKS1) is GenBank Accession no D88815. The corresponding amino acid sequence of C. albicans (CaFks1p) is GenBank Accession no. BAA21535. Sequences of other species are: Aspergillus fumigatus U79728; Aspergillus nidulans, AACD01000061; Candida glabrata; CR380953; Candida krusei, DQ017894; Cryptococcus neoformans, AAEY01000070; Paracoccidioides brasiliensis, AF148715; Neurospora crassa, XM327156; Pneumocystis carinii, AF191096; Saccharomyces cerevisiae U08459; Yarrowia lipolytica, CR382131.

Assays of this invention are directed to the nucleic acid sequences, preferably DNA sequences, corresponding to the two short amino acid sequences underlined in FIG. 2. Regarding the first underlined sequence, the first target sequence includes DNA or RNA that encodes minimally Phe₆₄₁ through Pro₆₄₉, (using CaFks1p as the reference) and optionally from one to five additional amino acids on either or both ends, preferably one or two. Regarding the second underlined sequence, the second target sequence includes DNA or RNA that encodes minimally Asp₁₃₅₇ through Leu₁₃₆₄, and optionally from one to five additional amino acids on either or both ends, preferably one or two.

Assays according to this invention include amplification of a first nucleic acid region that includes the first target sequence. Preferred assays according to this invention also include amplification of a second nucleic acid region that includes the second target sequence. Both the first and second regions can be amplified using a single primer pair spanning them both. Alternatively two pairs of primers can be utilized, a first pair spanning the first region and a second pair spanning the second region. Particularly if sequencing is to be utilized for detection of mutations in the target sequences, we prefer shorter amplicons and, hence, utilization of two primer pairs. As indicated above, assays of this invention are not restricted to a particular amplification. Our work to date has utilized the polymerase chain reaction (PCR) amplification, as is reflected in the Examples, but other methods may be used.

Detection of mutations in the target sequences may be by sequencing. As reflected in the Examples, we have utilized cycle sequencing, but other sequencing methods may be used. Detection of mutations in the target sequences may also be accomplished by utilization of hybridization probes that discriminate in the assay between the wild-type target sequence and sequences that include a mutation. Hybridization probes may be DNA, RNA or a combination of the two. They may include non-natural nucleotides, for example 2′O-methyl ribonucleotides. They may include non-natural internucleotide linkages, for example, phosphorothioate linkages. They may be PNA. Hybridization probes that are useful in assays of this invention include probes whose hybridization to an allele of a target sequence leads to a detectable signal. Preferred probes are fluorescently labeled and lead to a detectable florescent signal. Detection using hybridization probes can be end-point detection, that is, detection following the completion of amplification. Preferred probe assays of this invention are homogeneous assays, that is, assays that do not require separation of bound probes from unbound probes. More preferred homogeneous assays include real-time detection, most preferably real-time fluorescence detection, that is, detection multiple times during the course of amplification. For real-time amplification assays, we prefer dual fluorescently labeled probes, most preferably probes labeled with a fluorophore and also with a non-fluorescent quencher such as 4-(4′-dimethylamino-phenylazo)benzoic acid (DABCYL).

Any suitable probing method may be utilized for real-time assays, including methods that utilize hybridization probes in combination with DNA fluorescent dyes, such as SYBR dyes, that fluoresce in the presence of double-stranded DNA. For example, SYBR Green dye may be used to detect amplification, and an allele-discriminating fluorescent hybridization probe may be used to detect the amplification of a wild-type target sequence, with the slope of probe fluorescence indicating the presence of homozygous wild-type target, heterozygosity with mutant and wild-type target, or homozygous mutant target. Another approach would be to utilize a mismatch-tolerant probe to detect one strand of amplified target sequence (whether wild-type or mutant) and allele-specific probe or probes that are hybridizable to the other strand to determine whether or not the target sequence is mutated. Alternatively, multiple probes can be utilized to signal the presence of wild-type target sequence and specific mutations as is demonstrated in the Examples. We have identified several mutations in the first and second target sequences that result in caspofungin reduced susceptibility. In the first target sequence these are (using CaFKS1 as the reference) T1921C, T1922C, G1932T, T1933C, C1934A, C1934T, C1934G, G1942T and C1946A In the second target sequence these are (using CaFKS1 as the reference) C4081G and G4082A.

A wide range of molecular methods for mutation analysis and SNP genotyping are available. Among them, Real-time PCR with detection by self reporting molecular beacon probes represents a powerful approach. Due to their hairpin structure, thermodynamically conditioned equilibrium between intra- and inter-molecular hybridization allows molecular beacon probes to be designed to distinguish closely related target sequences with higher specificity and at wider temperature range comparing with corresponding linear probes. The discriminative power of molecular beacons has been successfully applied for analysis of mutations resulting in antibiotic resistance, allele differentiation, both homozygous and heterozygous SNPs, as well as for number of other applications.

The selectivity of molecular beacon probes was useful for analysis of CaFKS1 alleles conferring reduced susceptibility to caspofungin. The assay for the first target sequence, which we have designated the “HS1” sequence, focused on CaFKS1 codon 645 mutations T1933C, C1934A and C1934T, which have been identified with clinical isolates of C. albicans showing reduced susceptibility to caspofungin. The design of allele-specific probes for detecting resistance alleles in the target region was complicated by the fact that a SNP, T1929A, was located within this domain. To accommodate this SNP, which appears in a large proportion of clinical isolates, the probes were designed with a wobble base at the position corresponding to SNP. Introduction of the wobble base into the probe decreased the overall fluorescence output, since at the given conditions only half of probe molecular pool would bind specifically to the complementary target DNA. Nevertheless the gain from the higher versatility of degenerate probes far exceeded the loss of absolute fluorescence intensity since such probes were reactive for entire C. albicans population regardless of either presence or absence of T1929A SNP in CaFKS1.

Four degenerate molecular beacons corresponding to one wild type and three mutant CaFKS1 alleles were synthesized and all four probes showed excellent discrimination characteristics with match-to-mismatch signal ratio close to 100% for most targets. Only specific hybridization with complementary DNA targets was observed for all four probes. The only exception was a minor hybridization of molecular beacon CaFKS1-WT with the template containing the T1922C allele. This result can be explained by the lateral location of the mismatch in the probe domain as well as by the energetics of forming T•G mismatch, which is known to be a relatively stable DNA-DNA mismatch pairing. In the case of allele heterozygosity, the molecular beacon probes (recognizing wild type and mutant sequences) produced fluorescent signals one-half the magnitude compared with homozygous templates.

The generation of mutants with reduced susceptibility to caspofungin was a rare event and was consistent with a mutation frequency <10⁻⁸ mutants per viable cell. Formation of the resistant mutants required prolonged (>7 days) incubation on solid media containing caspofungin where residual cell growth occurred. We have never observed caspofungin resistant cells among C. albicans cultures not previously exposed to drug. Eight-five spontaneous reduced susceptibility mutants from two different strains were analyzed by the allele-specific molecular beacons. Mutations found in 35 isolates of strain CAI4 were identical to previously described substitutions affecting the codon for Ser₆₄₅. Such mutations also comprised a majority of the 50 caspofungin resistant derivatives of strain M70. Three new mutations, namely T1922C, G1932T and C1934G, affecting codons for Phe₆₄₁, Leu₆₄₄ and Ser₆₄₅ were detected in 6 strains of the spontaneous mutants derived from M70. These results are consistent with a recent mutational analysis of laboratory and clinical strains of C. albicans with reduced susceptibility to caspofungin. The vast majority of nucleotide substitutions were found in codon 645 of CaFKS1. The newly discovered mutations in other sites of CaFKS1 were found in progeny of only strain M70, and their relative frequency did not exceed 12%.

Overall, the application of individual molecular beacons allowed genotyping of all 85 caspofungin resistant derivatives. The three alleles targeted by molecular beacons were correctly identified in 79 strains, which was confirmed by DNA sequence analysis. The three new mutations not targeted by the molecular beacons in 6 strains were also confirmed by DNA sequence analysis. Multiplexing of all four molecular beacons in a single reaction produced universal closed tube assay for detection of caspofungin resistance mutations in the first target sequence of CaFKS1. In such assay FAM signal showed the presence of wild type CaFKS1 allele, whereas HEX fluorescence reported the presence of one of T1933C, C1934A or C1934T CaFKS1 mutations in DNA sample. DNA extracted from C. albicans strains heterozygous on any of above three mutations yielded both FAM and HEX signals. Thus the assay allowed for confident detection of known mutations in C. albicans CaFKS1 gene conferring reduced susceptibility to caspofungin in both homozygous and heterozygous state. The assay was also sensitive enough to identify other mutations in the region that can influence drug susceptibility.

As stated above, we shown that mutations linked to reduced susceptibility to caspofungin map to a short conserved regions in CaFKS1. The most prominent locus is Ser₆₄₅ and includes substitutions S645P, S645Y, S645F, which were found in both laboratory and clinical isolates of C. albicans. The mutations appeared to be dominant and conferred high level of caspofungin resistance in both heterozygous and homozygous state. Diagnostic probes that target such mutations can provide a rapid and accurate tool for assessment of resistance to caspofungin in C. albicans.

Rapid-diagnostics of caspofungin-resistance based on analysis of FKS1 mutations must have an ability to discriminate both heterozygous and homozygous alleles differing in single nucleotide as well as ability of simultaneous detection of such alleles in multiplex format. Molecular beacons technology represents an excellent technique for both allele discrimination and multiplex detection.

DNA sequence analysis of CaFKS1 from more than fifty clinical and laboratory C. albicans isolates with reduced susceptibility to caspofungin revealed three mutations, T1933C, C1934A and C1934T resulting in amino acid changes S645P, S645Y and S645F, respectively. Beside those nucleotide substitutions, alignment of sequencing data disclosed another point of variability in this region. In about 25% of all analyzed C. albicans strains, a T1929A single synonymous nucleotide substitution was observed, which was also reported in strain SC5314, as part of the Candida albicans genome sequencing project. This observation is significant because it has the potential to alter probe-amplicon hybridization necessary for discrimination by allele-specific probes that cover this region. Based on the CaFKS1 sequences consensus data, we designed four allele-specific molecular beacon probes that covered nucleotides 1920-1944. This work is reported in detail in the Examples. One probe was complementary to the wild type (WT) CaFKS1 allele found in caspofungin-susceptible C. albicans strains, while three probes were complementary to mutant CaFKS1 alleles (C1934A, C1934T, T1933C) observed in caspofungin-resistant isolates. All the beacons had identical 6-nucleotide long stem domains 5′CGCGAG and CTCGCG3′ and were synthesized with a wobble base A/T 50:50 at the position corresponding to the CaFKS1 SNP at the position 1929 to ensure their alignment to target sequences. Wild type molecular beacon CaFKS1-WT was labeled with FAM at 5′ end, whereas three mutant beacons were labeled with HEX at 5′ end. All molecular beacons had 3′ end modified with DABCYL quencher. Specifics of primer and probe design are described in Example 3. The discrimination temperature window for the probes is described in Example 4. Detection was performed in the window.

Spontaneous mutants of C. albicans strains CAI4 and M70 resistant to caspofungin were isolated by direct selection on solid growth media containing 4 μg/ml (forty times the MIC) caspofungin. The frequency of formation of spontaneous caspofungin-resistant derivatives for both strains was <10⁻⁸ mutants per viable cell. For both strains, the formation of rare shrunken slow-growing colonies on the plates with caspofungin was observed. The colonies were streaked on fresh plates containing the same amount of caspofungin and did not produce any growth. After prolonged incubation for more than 10 days, a small fraction of small shrunken colonies gave rise to smooth fast-growing derivatives which were able to propagate on caspofimgin-containing media after reinoculation. Only one such derivative per individual plate/culture was saved and used for further analysis. In total, 35 and 50 isolates with reduced susceptibility to caspofungin were isolated for strains CAI4 and M70, respectively. In vitro caspofungin susceptibility testing revealed elevated MIC values >16 μg/ml of caspofungin for all laboratory-derived isolates. Details of the isolation procedure are set forth in Example 2.

The preliminary sequencing of CaFKS1 gene of CAI4 and M70 strains (See Example 2) revealed the existence of T1929A SNP in the CaFKS1 gene from CAI4 and its absence in M70. Chromosomal DNA was extracted from parental strains CAI4 and M70 and their caspofungin-resistant derivatives and was used as template for real-time PCR experiments with CaFKS1 molecular beacons. FIG. 4 gives the nucleotide sequence of the various targets, both wild-type and mutant, and primers and molecular beacon probes utilized. In FIG. 4 the probe domains of the probes and the target sequences of target strands are underlined. Bases in probes and target sequence that correspond to mutations in HS1 regions of CaFKS1 are in boldface. Base positions designated W indicate an equimolar mixture of two degenerate molecular beacons differing only by A or T at that position. Each chromosomal DNA sample was subjected to four separate PCR reactions with individual molecular beacon probes representing the different reduced susceptibility alleles: The real-time PCR protocol is described in Example 5. An annealing temperature of 61° C. was applied for all reactions, which allowed excellent discrimination between different CaFKS1 alleles (see Example 4). Mutant CaFKS1 alleles were found for all 35 caspofungin-resistant derivatives of strain CAI4. A majority of them (20 isolates) had the heterozygous mutation wt/T1933C, while 15 mutants contained the homozygous mutations T1933C, C1934A or C1934T. In the case of heterozygosity at T1933C, two signals of similar magnitude from molecular beacons CaFKS1-WT and CaFKS1-T1933C resulted (FIG. 5). FIG. 5 results of four separate PCRs with individual molecular beacons and DNA targets.

CaFKS1-T1933C beacon+DNA of CaFKS1 allele with homozygous T1933C mutation,

CaFKS1-WT beacon+DNA of CaFKS1 allele with homozygous T1933C mutation,

CaFKS1-T1933C beacon+DNA of CaFKS1 allele with heterozygous T1933C mutation,

CaFKS1-WT beacon+DNA of CaFKS1 allele with heterozygous T1933C mutation.

FIGS. 6A-6D show the discrimination of ten CaFKS1 homozygous alleles by four molecular beacons CaFKS1-WT (FIG. 6A), CaFKS1-T1933C (FIG. 6B), CaFKS1-C1934A (FIG. 6C) and CaFKS1-C1934T (FIG. 6D). Each plot summarizes results of eleven individual PCRs with individual DNA alleles bearing mutations:

wild type (no mutations or SNP),

T1933C,

C1934A,

C1934T,

T1929A SNP,

T1933C+T1929A SNP,

C1934A+T1929A SNP,

C1934T+T1929A SNP,

T1922C,

G1932T+C1934G,

blank (no DNA).

DNA samples with homozygous CaFKS1 mutations yielded distinct responses from corresponding mutant molecular beacons with no signal from CaFKS1-WT (FIGS. 6B-6D). Conversely, chromosomal DNA from the parental strain CAI4 interacted only with the CaFKS1-WT probe while no fluorescence was detected from the mutant beacons (FIG. 6A).

Genotyping of CaFKS1 alleles of caspofungin-resistant derivatives of strain M70 revealed known mutations T1933C, C1934A or C1934T in 44 out of 50 samples. As in the case with the CAI4 mutants, a majority of M70 derivatives acquired heterozygous mutations T1933C. It was found that 25 of 50 strains with decreased susceptibility harbored the T1933C substitution in one CaFKS1 copy. Heterozygous mutations C1934A and C1934T were detected in 6 strains. All real-time PCR involving DNA samples with heterozygous mutations T1933C, C1934A or C1934T yielded two kinds of fluorescence signals from the CaFKS1-WT molecular beacon and one of the three mutant molecular beacons CaFKS1-T1933C, CaFKS1-C1934A or CaFKS1-C1934T. Beside heterozygous mutations at the positions 1933 and 1934 of CaFKS1, homozygous substitutions at these sites were also detected in 13 strains, which were identified by specific hybridization with corresponding mutant molecular beacons CaFKS1-T1933C, CaFKS1-C1934A or CaFKS1-C1934T (FIGS. 6B-6D).

In 6 of the 50 strains, PCR amplification of chromosomal DNA was only weakly detected by the wild type molecular beacon and not at all by the mutant molecular beacons (5 strains) and one strain was not detected by both wild type and mutant molecular beacons. Given the allele specificity of the probes, these data suggest that the template sequence was altered in an unknown manner.

DNA sequencing of CaFKS1 from of all caspofungin-resistant strains CAI4 and M70 was used to confirm the results of real-time PCR and to clarify the unresolved issues with six M70 derivatives. A 100% correlation between real-time PCR results and sequencing results was found for all 35 CAI4 derivatives and 44 M70 derivatives. All heterozygous and homozygous mutations detected at positions 1933 and 1934 of CaFKS1 in real-time PCR experiments by hybridization with molecular beacons CaFKS1-T1933C, CaFKS1-C1934A or CaFKS1-C1934T were confirmed by DNA sequencing. The existence of a new homozygous mutation T1922C was found in CaFKS1 gene of the five M70 derivatives which showed ambiguous results in real-time PCR experiments. Furthermore, DNA sequencing uncovered two new homozygous mutations, G1932T and C1934G, in the CaFKS1 gene of the one M70 caspofungin-resistant derivative which failed to produce any fluorescence response in real-time PCR. As expected all derivatives of strain CAI4 had T1929A SNP, whereas derivatives of strain M70 lacked it, which was revealed by sequencing.

The separate application of CaFKS1 molecular beacons made possible genotyping of three known mutations in the C. albicans CaFKS1 gene. We further investigated the possibility of combining all four degenerated CaFKS1 molecular beacons in multiplex real-time PCR format suitable for simultaneous assessment of such mutations in a given DNA sample. See Example 5. We pooled together all four CaFKS1 molecular beacons, labeled with different fluorophores for wild type and mutant, in aggregate probe mixture which was added to individual PCRs. Chromosomal DNAs from wild type strains CAI4 and M70 and 12 caspofungin resistant derivatives of these strains representing 12 different CaFKS1 genotypes were used as templates for multiplex real-time PCRs. The conditions for multiplex real-time PCR experiments were identical to those of real-time PCR with individual molecular beacons with the only exception of an annealing temperature of 60° C. The wild type molecular beacon CaFKS1-WT was labeled by FAM and mutant molecular beacons CaFKS1-T1933C, CaFKS1-C1934A or CaFKS1-C1934T were labeled by HEX. Using these probes, we were able to identify caspofungin susceptible and caspofungin resistant strains by the nature of fluorescence output.

FIG. 7 illustrates the graphic output of Stratagene MX4000 software for the multiplex real-time PCR assay of CaFKS1 mutations. The top semicircle is highlighted when FAM signal is observed, reporting the presence of wild type CaFKS1 DNA. The bottom semicircle is highlighted when HEX signal is observed, reporting the presence of any of three shown mutations in CaFKS1 DNA. Homozygous CaFKS1 alleles produce either FAM or HEX signals, whereas heterozygous CaFKS1 alleles produce both FAM and HEX signals.

Only FAM fluorescence was observed when DNA from susceptible strains CAI4 and M70 was subjected to multiplex real-time PCR. Only HEX fluorescence was reported in multiplex real-time PCR with DNA bearing homozygous mutations T1933C, C1934A or C1934T in CaFKS1 (FIG. 7). Both FAM and HEX signals of equal magnitude were detected when analyzed DNA was from strains known to have heterozygous mutations T1933C, C1934A or C1934T in CaFKS1 gene (FIG. 7). Multiplex real-time PCR with chromosomal DNA from strain having two new mutations G1932T and C1934G in CaFKS1 yielded neither FAM nor HEX fluorescence. Minor FAM signals were observed in the reaction with chromosomal DNA from the strain containing a homozygous mutation T1922C.

We have also designed primers and probes for the second target region, which we refer to as “HS2,” specifically for one mutant, G4082A. This is reported in Example 6. A mutant probe could be similarly designed for mutant C4081G or any other such mutant in designing assays that include the second target region, either separately or multiplexed for HS2 or for HS1 and HS2 as described in the previous Examples.

Example 1

Nucleic acid amplification of pertinent fragments of the CaFKS1 gene coupled with cycle sequencing for mutant identification has been demonstrated utilizing four different strains. Fragments of CaFKS1 (ca. 450 bp) were amplified from genomic DNA from strains CAI4-R1, NR2, NR3, and NR4. The sense and antisense primers used for PCR, based on CaFKS1 sequence (GenBank Accession no. D88815), were 5′-GAAATCGGCATATGCTGTGTC-3′ (SEQ ID NO: 21) and 5′-AATGAACGACCAATGGAGAAG-3′ (SEQ ID NO: 22), respectively. PCR products were cloned into pCR2.1 (Invitrogen) and the DNA sequence was determined. For clinical Candida isolates, a larger portion of the CaFKS1 ORF (ca 2.6 kb) was amplified for DNA sequence analysis using 5′-CATTGCTGTGGCCACTTTAG-3′ (SEQ ID NO: 23) and 5′-GGTCAAATCAGTGAAAACCG-3′ (SEQ ID NO: 24) as the forward and reverse primers, respectively. In addition to the first target region of CaFKS1 described above (corresponding to coding nucleotides 1921-1947), this fragment includes the second target nucleotides 4069-4092. The PCR products were purified, quantified by fluorescence labeling (Pico Green, Molecular Probes), and sequenced in both the 5′ and 3′ directions using the DTCS Quick Start Kit (Beckman Coulter).

Example 2

DNA sequence analysis using nucleic acid amplification and cycle sequencing can be used both as an assay technique in its own right and as a control to evaluate probe-based assays.

C. albicans chromosomal DNA was extracted from cells grown overnight in liquid YPD medium with Q-Biogene FastDNA kit (Q-Biogene, Irvine, Calif.). PCR experiments were performed on an iCycler thermocycler (Bio-Rad Laboratories, Hercules, Calif.). The CaFKS1 region denominated HS1 was amplified using primers CaFKS1-F1719 and CaFKS1-R2212 (FIG. 4). Each 100-μl PCR reaction contained 0.25 μM of each primer, 2.5 U of iTaq DNA polymerase (Bio-Rad Laboratories, Hercules, Calif.), 0.5 mM dNTPs, 50 mM KCl, 4 mM MgCl₂, 20 mM Tris-HCl, pH=8.4 and about 50 ng of C. albicans chromosomal DNA. The cycling conditions were 1 cycle of 3 min at 95° C., 35 cycles of 30 s at 95° C., 30 s at 55° C., 1 min at 72° C. 1 cycle of 3 min at 72° C. PCR products were purified using the Montage PCR purification kit (Millipore, Bedford, Mass.). PCR products for sequencing were obtained and purified using CEQ™ Dye Terminator Cycle Sequencing Quick Start kit (Beckman Coulter, Fullerton, Calif.) according to manufacturer recommendations on iCycler thermal cycler. Primers CaFKS1-F1719 or CaFKS1-R2212 were used for the sequencing reaction. The cycling conditions for sequencing PCR were 1 cycle of 3 min at 95° C., 30 cycles of 20 s at 96° C., 20 s at 50° C., 1 min at 60° C. All DNA sequencing was performed on CEQ™ 8000 Genetic Analysis System (Beckman Coulter, Fullerton, Calif.). CEQ™ 8000 Genetic Analysis System Software (Beckman Coulter, Fullerton, Calif.) was used for hardware control as well as for post run sequencing results analysis.

C. albicans strain CAI4 was purchased from ATCC (ATCC, Manassas, Va.). C. albicans strain M70 was from the Merck culture collection (MRL, Rahway, N.J.). Strains were grown on yeast extract-peptone-dextrose (YPD) medium (1% yeast extract, 2% Bacto Peptone, 2% dextrose). For growth of strain CAI4; YPD medium was supplemented by uridine (Sigma-Aldrich, St. Louis, Mo.) at 25 mg/ml. Caspofungin (Merck, Rahway, N.J.) was added directly to YPD at 4 μg/ml. Agar plates were incubated at 30° C. and liquid cultures were grown in 12-ml culture tubes containing 3 ml of YPD on the rotary shaker (100 rpm) at 30° C. Susceptibility to caspofungin was estimated in liquid microbroth dilution assay in RPMI-1640 medium (Sigma-Aldrich, St. Louis, Mo.), as outlined in NCCLS document M27-A2.

Spontaneous caspofungin-resistant mutants of C. albicans strains CAI4 and M70 were isolated by plating 100 ul (˜10⁸ cells) of an 18 h liquid YPD culture on YPD plates containing 4 μg/ml caspofungin. Serial dilutions of the overnight cultures were plated on the YPD plates without antibiotic selection to precisely determine starting colony counts. Selection plates were incubated for 10-14 days at 30° C. From each selection plate, at least 4 individual colonies resistant to drug were reinoculated on fresh caspofungin-containing plates to confirm the resistant phenotype.

Example 3

Three reported DNA sequences CaFKS1 GenBank accession numbers D88815 and AF027295 and CA2043) were used for FKS1 molecular beacons and primers design. Design of primers and probes for assays in known in the art. Numerous publications are available to assist researchers. Additionally, computer software packages are available to speed the process and reduce adjustments that need to be made by trial and error (see Example 4). We used such a software package. Molecular beacons and DNA primers (FIG. 4) were designed using Beacon Designer 3.0 software (PREMIER Biosoft, Palo Alto, Calif.). The default software parameters were applied for all molecular beacons and primers construction. Molecular beacons were labeled with fluorophores 5-carboxyfluorescein (FAM) and 6-carboxy-2′,4,4′,5′,7,7′-hexachlorofluorescein (HEX) at the 5′ end and with dabcyl at the 3′ end. Both molecular beacons and primers were purchased from Biosearch Technologies (Biosearch Technologies, Novato, Calif.). Hybridization properties for the CaFKS1 allele specific molecular beacons were tested for the full temperature range, 25° C.-95° C., with single-stranded target oligonucleotides (FIG. 4). Molecular beacon-target hybridization was performed with the Stratagene MX4000 Multiplex Quantitative PCR system (Stratagene, La Jolla, Calif.). The “Molecular Beacon Melting Curve” experiment type was chosen in the MX4000 software for data monitoring and analysis. Each 50-μl hybridization reaction mixture contained 1× Stratagene Core PCR buffer, 4 mM M_(g)Cl₂, 100 pmol of individual target oligonucleotide and 5 pmol of molecular beacon. The thermal conditions of experiment comprised heating at 95° C. for 3 minutes and cooling to 80° C. with subsequent cooling down to 25° C. using 112, 30-seconds steps with a temperature gradient −0.5° C. Fluorescence output for each individual reaction was measured at the end of the cooling step. The final data of the “Molecular Beacon Melting Curve” experiment were converted to a “SYBR Green (with Dissociation. Curve)” type of experiment. Melting temperature (T_(m)) for each molecular beacon-target pair was determined by MX4000 software as a temperature point corresponding to maximal value of the first derivative of the fluorescence output −R′(T). Each thermal profiling experiment was performed in triplicate.

Example 4

The ability of nucleic acid hybridization probes to discriminate between or among alleles is temperature-dependent; that is, if a probe discriminates against a sequence differing from target by one nucleotide at 70° C., it probably will bind to mismatched targets at 40° C. and not discriminate at such a lowered temperature.

We analyzed the allele-discriminating capability of probes as part of the probe design and assay design. Hybridization profiles were determined for molecular beacons probes against eight DNA oligonucleotide templates representing the wild-type CaFKS1 and different CaFKS1 alleles bearing caspofungin resistance mutations at positions 1933 and 1934, as well as the SNP at position 1929 (FIG. 4). The oligonucleotides described as “target” in FIG. 4 were used for melt-curve analysis of the probes. In the several target sequences, the underlined portions are complementary to one probe, as indicated, additional terminal repetitive adenosines were added to reduce secondary structure formation during melt-curve analysis. First, the hybridization of each of molecular beacon probe was assessed with two DNA targets complimentary to the probe domain sequence, which varied in the nucleotide base counterpart to the SNP at the position 1929. Each degenerate molecular beacon probe formed two types of intermolecular hybrids with such DNA targets. Stable hybrids were formed by the target oligonucleotide and a subpopulation of molecular beacon with complimentary sequence. Another subpopulation of molecular beacon probes having a single mismatched nucleotide at position 1929 formed less stable hybrid with same DNA target. As a consequence, the melting curves for the mixed probes represented as first derivative of the fluorescence output (−R′(T)) showed two distinct peaks corresponding to T_(m)s for more stable and less stable molecular beacon-target hybrids. Next we investigated the hybridization of each of molecular beacons with non-complementary DNA oligonucleotides (FIG. 4). Whereas such mismatched hybrids were generally less stable than complement, the degeneracy of molecular beacons produced the same trend for the two hybrid subpopulations. More stable intermolecular hybrids were formed by the target oligonucleotide and beacon subpopulation with single mismatch, whereas less stable hybrids comprised oligonucleotide and beacon subpopulation with double mismatches. Out of two T_(m) values obtained for each of eight pairs of degenerated molecular beacons and target oligonucleotides only higher T_(m) value corresponding to more stable beacon-target hybrid with one or no mismatches was taken into account. The T_(m) values for CaFKS1 molecular beacons and their complementary DNA targets were quite close to each other and fall down to the temperature range 62.7-64.0° C. The corresponding windows of discrimination occupy the similar thermal diapason as well. Such uniformity was achieved by varying the length of the probe domain sequence for individual beacons. Molecular beacon CaFKS1-WT, CaFKS1-T1933C, CaFKS1-C1934A and CaFKS1-C1934T had probe domains of 24, 23, 25 and 25 nucleotides long correspondingly.

Example 5

A real-time amplification assay was demonstrated for the primers and probes described in FIG. 4. The assay included DNA amplification by the polymerase chain reaction (PCR) with real-time detection utilizing molecular beacon probes.

For assays employing each single probe (FIG. 4), the procedure was as follows. Real-time PCR experiments were performed on a Stratagene Mx4000 Multiplex Quantitative PCR System using the “Quantitative PCR (Multiple Standards)” setting. Reagents from Brilliant® QPCR Core Reagent kit (Stratagene, La Jolla, Calif.) were used for all reactions. Each 50-μ1 PCR reaction contained 1× Stratagene Core PCR buffer, 0.2 μM of molecular beacon, 0.25 μM of each of the HS1AN2 and HS1SN2 primers (FIG. 4), 2.5 U of SureStart® Taq DNA polymerase (Stratagene, La Jolla, Calif.), 0.4 mM dNTPs, 4 mM MgCl₂ and about 50 ng of C. albicans chromosomal DNA. In multiplex PCR experiments, the concentration of each of the four molecular beacons (FIG. 4) was 0.2 μM. Real-time PCR thermal cycler parameters were: 1 cycle of 10 min at 95° C., 45 cycles of 30 s at 95° C., 30 s at 61° C. and 30 s at 72° C. An annealing temperature of 60° C. was used when PCR experiments were performed in multiplex format. The filter gain set of the Mx4000 System was changed to FAM-960 HEX-720 with an aim of equalization of the fluorescence signal magnitudes from different molecular beacons. The fluorescence was measured 3 times during the annealing step.

Fluorescence signals coming from Stratagene Mx4000 System during PCR amplification were monitored using Mx4000 software in real time. At the end of each run, the amplification plots data were converted to graphic format and stored as image files or exported into Microsoft Office Excel and stored as spreadsheet files. In the case of multiplex PCR reactions, the final results of PCR amplifications were converted from a “Quantitative PCR (Multiple Standards)” type of experiment to the “Quantitative Plate Read” type of experiment. Total changes in fluorescence for individual fluorophores (Rpost-Rpre) were taken as values for analysis. Results were converted to graphic or numerical format and stored as image or spreadsheet files.

For multiplex assays we utilized PCR amplification as described above, except that the annealing temperature of the thermal cycles was 60° C. rather than 61° C. Multiple probes were utilized in the same reaction.

Example 6

Primers and molecular beacon probes for PCR amplification assays have been designed for the second DNA sequence, which we refer to as HS2. The primers have the following sequences:

(SEQ ID NO: 25) CCATTTGGTTGTTACAATATTGC-3′ (SEQ ID NO: 26) CCAATGGAATGAAAGAAATGAAG-3′.

To distinguish the wild-type gene sequence from the echinocandin-resistant mutant G4082A, the nucleotide sequences for a pair of allele-discriminating molecular probes was designed. Each would be labeled at one end with a fluorophore and at the other end with a non-fluorescent quencher such as DABCYL. Of course, differentiable fluorophores would be utilized such that the wild-type probe would hybridize only to the wild-type gene sequence and thereupon fluoresce, and the mutant probe would hybridize only to the mutant sequence and thereupon fluoresce in end-point assays and real-time amplifications containing one of these probes, or in multiplexed assays containing both probes, with or without primers and probes for the first target sequence.

The molecular beacon probes have single-stranded loops that are 24 nucleotides in length flanked by complementary 3′ and 5′ arm sequences that form a 6-nucleotide stem. Both probes have a calculated T_(m) of 61.5° C. Their sequences are:

(SEQ ID NO: 27) Wild-type probe: CGCGAGGATTGGATTAGACGTTATACTTTGCTCGCG (SEQ ID NO: 28) Mutant probe: CGCGAGGATTGGATTAGACATTATACTTTGCTCGCG.

Where the complementary arms are underlined and the single nucleotide changed in the mutant is bolded.

A number of embodiments of the invention have been described. Nevertheless, it will be understood that various modifications may be made without departing from the spirit and scope of the invention. For example, amplification methods other than PCR can be used, for example NASBA, and allele-discriminating probes other than molecular beacon probes can be used. Accordingly, other embodiments are within the scope of the following claims. 

What is claimed is:
 1. A nucleic acid assay for detecting echinocandin drug resistance mutations in fungi susceptible to echinocandin drugs and containing the FKS1 gene corresponding to 1-3β-D-glucan synthase subunit Fks1p comprising exponentially amplifying a first nucleic acid target sequence of the FKS1 gene corresponding to at least a portion of CaFks1p amino acids 636 to 654 that includes amino acids 641 to 649 to generate an amplified first target sequence, contacting the amplified first target sequence with a first labeled hybridization probe specific for an amino acid mutation selected from the group consisting of S645P, S645Y, and S645F of CaFks1p, and detecting the presence of the mutation, thereby detecting an echinocandin drug resistance mutation.
 2. The assay of claim 1 wherein the fungi are a Candida species.
 3. The assay of claim 1, further comprising contacting the amplified first target sequence with an additional labeled hybridization probe specific for at least one amino acid mutation selected from the group consisting of F641L, F641S, D648Y and P649H of CaFks1p.
 4. The assay according to claim 1 wherein the step of amplifying includes amplifying a second nucleic acid target sequence of the FKS1 gene corresponding to 1-3-β-D-glucan synthase subunit Fks 1 p corresponding to at least a portion of CaFks1p amino acids 1345 to 1369 that includes amino acids 1357 to 1364 to generate an amplified second target sequence, and wherein the step of detecting includes detecting any difference from the wild-type allele in said amplified second target sequence.
 5. The assay of claim 4 that is capable of detecting at least one amino acid change selected from the group consisting of R1361H and R1361G of CaFks1p.
 6. The assay of claim 4 wherein amplification of the first target sequence and the second target sequence are performed in the same reaction mixture.
 7. The assay of claim 1 wherein the step of detecting further comprises sequencing.
 8. The assay of claim 4 wherein the step of detecting comprises contacting the amplified second target sequence with a second labeled hybridization probe specific for at least one amino acid mutation selected from the group consisting of R1361H and R1361G of CaFks1p.
 9. The assay of claim 8 wherein detection is homogeneous end-point or real-time detection.
 10. The assay according to claim 9, wherein the detection is a real-time detection.
 11. The assay according to claim 1 wherein the step of amplifying includes an amplification method selected from the group consisting of PCR, NASBA and TMA.
 12. The assay of claim 1, wherein the amplifying step is conducted in a sample obtained from a human or from a clinical isolate. 